58 year old male patient with fever shortness of breath and sweating

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints:

58 yr old male patient was admitted with chief complaints of Shortness of breath , Sweating , fever.

 

HOPI :- 

Patient was apparently asymptomatic 7 yrs back then he went to checkup for fever then was diagnosed as Diabetic and aslo with hypotension and was taking medications since then.

Then after 2 yrs he developed ulcers on both the legs after an injury during the field work and there was skin peeling also.

Thereafter he was on a diet for 4 months {which includes drinking organic coconut oil,taking only liquid foods, Vegetables that made him lose his weight (100 to 75 kg)} was healthy but he developed skin infections (fungal) on the lower abdomen and legs and was on medications. 

After a year he developed muscle spasm in the left leg and back pain for which he took various unprescribed painkillers (for 2yrs).he also went for physiotherapy 5-6 months back.

3 months back he met with an RTA and had an left ankle injury which was non healing even on medication.

Patient started consuming alcohol at the age of 15 and then continued till he was 30 and stopped.

 8 yrs back he started drinking alcohol again due to depression after his son died and stopped when he developed leg ulcers(5 yrs back).

1yr back he consumed alcohol 2-3 times and stopped.

5 days back he started consuming toddy ( after dinner) daily for 3 days.First 2 days he was normal but on the 3rd day before going to sleep at night he started having shortness of breath ( grade 4 ), Sweating, fever and gas trouble.

He was treated by private practitioner on the same night but his condition was not improving so he was shifted to the hospital.

Past history:

K/c/o Diabetes and hypotension

Not a k/c/o Asthma,TB, Thyroid disorders, Epilepsy

Personal history:

Diet:mixed

Appetite: Normal

Sleep: adequate 

Bowel and bladder movements: regular

Family history: No significant family history

GENERAL EXAMINATION:-

Patient is conscious coherent and cooperative

Well oriented to time place and person

No Pallor, icterus, Cyanosis,Clubbing, Lymphadenopathy 

Bilateral pedal Edema is seen (left more than right).

Vitals:-

Temp: afebrile at the time of examination

HR:112 bpm

BP:80/50

RR: 36 cpm

SYSTEMIC EXAMINATION:

Cvs: s1 s2 heard no murmurs

Respiratory: Dyspnea is present

                      NVBS , Bilateral air entry seen.

CNS: conscious, Normal speech, No focal neurological deficit.

Per abdomen: Abdomen is obese and distended, soft and non tender.

Investigations:

CBP 

ECG 

                                     5th july 2022

                                     6th july 2022

USG

X Ray 

2D Echo

Provisonal diagnosis 

Sepsis 2⁰ to left lower limb cellulitis with metabolic acidosis.